Overarching challenges to the implementation of competency-based medical education.

Medical education is under increasing pressure to more effectively prepare physicians to meet the needs of patients and populations. With its emphasis on individual, programmatic, and institutional outcomes, competency-based medical education (CBME) has the potential to realign medical education with this societal expectation. Implementing CBME, however, comes with significant challenges. This manuscript describes four overarching challenges that must be confronted by medical educators worldwide in the implementation of CBME: (1) the need to align all regulatory stakeholders in order to facilitate the optimization of training programs and learning environments so that they support competency-based progression; (2) the purposeful integration of efforts to redesign both medical education and the delivery of clinical care; (3) the need to establish expected outcomes for individuals, programs, training institutions, and health care systems so that performance can be measured; and (4) the need to establish a culture of mutual accountability for the achievement of these defined outcomes. In overcoming these challenges, medical educators, leaders, and policy-makers will need to seek collaborative approaches to common problems and to learn from innovators who have already successfully made the transition to CBME.

Reconceptualizing variable rater assessments as both an educational and clinical care problem.

The public is calling for the U.S. health care and medical education system to be accountable for ensuring high-quality, safe, effective, patient-centered care. As medical education shifts to a competency-based training paradigm, clinician educators' assessment of and feedback to trainees about their developing clinical skills becomes paramount. However, there is substantial variability in the accuracy, reliability, and validity of the assessments faculty make when they directly observe trainees with patients. These difficulties have been treated primarily as a rater cognition problem focusing on the inability of the assessor to make reliable and valid assessments of the trainee.The authors' purpose is to reconceptualize the rater cognition problem as both an educational and clinical care problem. The variable quality of faculty assessments is not just a psychometric predicament but also an issue that has implications for decisions regarding trainee supervision and the delivery of quality patient care. The authors suggest that the frame of reference for rating performance during workplace-based assessments be the ability to provide safe, effective, patient-centered care. The authors developed the Accountable Assessment for Quality Care and Supervision equation to remind faculty that supervision is a dynamic, complex process essential for patients to receive high-quality care. This fundamental shift in how assessment is conceptualized requires new models of faculty development and emphasizes the essential and irreplaceable importance of the clinician educator in trainee assessment.

Practice-based learning can improve osteoporosis care.

OBJECTIVES: To examine physician engagement in practice-based learning using a self-evaluation module to assess and improve their care of individuals with or at risk of osteoporosis. DESIGN: Retrospective cohort study. SETTING: Internal medicine and subspecialty clinics. PARTICIPANTS: Eight hundred fifty U.S. physicians with time-limited certification in general internal medicine or a subspecialty. MEASUREMENTS: Performance rates on 23 process measures and seven practice system domain scores were obtained from the American Board of Internal Medicine (ABIM) Osteoporosis Practice Improvement Module (PIM), an Internet-based self-assessment module that physicians use to improve performance on one targeted measure. Physicians remeasured performance on their targeted measures by conducting another medical chart review. RESULTS: Variability in performance on measures was found, with observed differences between general internists, geriatricians, and rheumatologists. Some practice system elements were modestly associated with measure performance; the largest association was between providing patient-centered self-care support and documentation of calcium intake and vitamin D estimation and counseling (correlation coefficients from 0.20 to 0.28, Ps < .002). For all practice types, the most commonly selected measure targeted for improvement was documentation of vitamin D level (38% of physicians). On average, physicians reported significant and large increases in performance on measures targeted for improvement. CONCLUSION: Gaps exist in the quality of osteoporosis care, and physicians can apply practice-based learning using the ABIM PIM to take action to improve the quality of care.

Early feedback on the use of the internal medicine reporting milestones in assessment of resident performance.

BACKGROUND: The educational milestones were designed as a criterion-based framework for assessing resident progression on the 6 Accreditation Council for Graduate Medical Education competencies. OBJECTIVE: We obtained feedback on, and assessed the construct validity and perceived feasibility and utility of, draft Internal Medicine Milestones for Patient Care and Systems-Based Practice. METHODS: All participants in our mixed-methods study were members of competency committees in internal medicine residency programs. An initial survey assessed participant and program demographics; focus groups obtained feedback on the draft milestones and explored their perceived utility in resident assessment, and an exit survey elicited input on the value of the draft milestones in resident assessment. Surveys were tabulated using descriptive statistics. Conventional content analysis method was used to assess the focus group data. RESULTS: Thirty-four participants from 17 programs completed surveys and participated in 1 of 6 focus groups. Overall, the milestones were perceived as useful in formative and summative assessment of residents. Participants raised concerns about the length and complexity of some draft milestones and suggested specific changes. The focus groups also identified a need for faculty development. In the exit survey, most participants agreed that the Patient Care and Systems-Based Practice Milestones would help competency committees assess trainee progress toward independent practice. CONCLUSIONS: Draft reporting milestones for 2 competencies demonstrated significant construct validity in both the content and response process and the perceived utility for the assessment of resident performance. To ensure success, additional feedback from the internal medicine community and faculty development will be necessary.

The ABIM's clinical supervision practice improvement module and its effect on faculty's supervisory skills.

PURPOSE: Inadequate supervision of medical trainees hampers education and patient care. The authors examine the use of the American Board of Internal Medicine's Clinical Supervision Practice Improvement Module (CS-PIM) to determine whether it facilitated and enhanced faculty's skills in direct observation, providing feedback, identifying errors, and auditing medical records. METHOD: In this descriptive cohort study, module satisfaction was assessed using a five-point Likert scale. Changes in supervisory skills were measured using a retrospective pre-/postmodule self-assessment; deltas were compared by the Wilcoxon signed rank test. RESULTS: Between March 2009 and October 2010, 644 faculty completed 647 CS-PIMs. Asked how effective the module was for improving their observation and evaluation skills, 91% rated it excellent, very good, or good. Similarly high percentages of the faculty gave those same ratings to the module for facilitating documenting trainee evaluations, documenting feedback to trainees, reflecting on the summary report, developing an improvement plan, and documenting their self-assessment of supervisory skills. Faculty self-reported improved skills in observation, giving feedback, identifying errors, and auditing medical records. CONCLUSION: The CS-PIM facilitated and improved faculty skills in the supervision of trainees and led to self-reported changes in supervisory practices. Future research should evaluate trainees' perceptions and the actual impact on quality of care in the teaching setting.

Competency-based education and training in internal medicine.

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.